Failure to Administer Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Friedreich ataxia and functional quadriplegia did not receive Clonazepam 0.5 mg as ordered by the physician. The medication was scheduled to be administered twice daily at 8:00 AM and 8:00 PM, but was not given at the scheduled 8:00 PM dose. Documentation on the Medication Administration Record indicated the medication was not administered due to it being unavailable, with a note that the facility was awaiting delivery from the pharmacy for a new admission. Further investigation revealed that the facility had an Omnicell automated medication dispensing system stocked with Clonazepam 0.5 mg, with six tablets available at the time. Staff confirmed that the medication could have been accessed from the Omnicell after verifying the order with the pharmacy, but this was not done. The Director of Nursing confirmed that the medication had not been administered and that staff would have needed to contact the physician for clarification due to the late delivery, but this step was not taken.